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Adapted from the CDC Guidelines for Preventing
Healthcare-Associated Pneumonia, 2003.
Most initiatives for reducing VAP can be readily
Avoid the use of antacids and histamine type-2
incorporated into standard care for ventilated patients
antagonists — Patients on mechanical ventilation are
without incurring significant expenditure of resources.
subject to gastrointestinal hemorrhage (stress ulcers).
Antacids and histamine type-2 antagonists are often
Wash hands — Washing hands or the use of alcohol-
used protectively. Unfortunately, they also alter the
based antiseptic solutions has been shown to reduce
acidic environment allowing bacteria to colonize the
nosocomial infections. Clean hands between patients,
area while increasing gastric volume and distension.
after glove removal, before clean and after dirty tasks.
Regurgitation and subsequent aspiration can cause
VAP. Alternatively, sucralfate has been advocated as it
Wear gloves and gowns as appropriate — Change
neither decreases acidity nor increases gastric volume.
gloves between patients and between contaminated
However, more recent studies have had variable results
and clean procedures on the same patient. Use sterile
gloves when appropriate to protect the patient (e.g.
Use of post-pyloric rather than gastric feeding has
suctioning). Gloves and gowns have been shown to beeffective in preventing the spread of Vancomycin-
benefits — A gastric feeding tube violates the
Resistant Enterococci (VRE) and MRSA.
gastroesophageal (cardiac) sphincter. This can permit
gastric reflux which can travel up the esophageal tract
Make patient oral hygiene standard practice —Routine
to the subglottic space then subsequently aspirated
oral decontamination is an effective method for
around the cuff. The percutaneous delivery of nutrients
reducing VAP by decreasing the microbial load in the
into the small bowel (post-pyloric) prevents
oropharyngeal cavity. It has been found that the
gastroendotracheal delivery-related gastric reflux,
incorporation of routine oral hygiene into standard
gastric over-distension, and peptic acid alteration,
practice reduced VAP by 57.6%. Oral hygiene programs
reducing VAP risk. The overall optimal approach for
should consist of frequent tooth brushing, oral
feeding the ventilated patient is undefined; however,
suctioning and swabbing of the mouth with antiseptic
post-pyloric feeding is associated with an overall
Implement Common Suction Protocol — Standardized
Utilize methods for early diagnosis of VAP — Early
endotracheal suction protocols, in which everyone
recognition of VAP and identification of the causative
suctions effectively in the same way, have been shown
pathogen(s) insures early use of the appropriate
to reduce colonization and the incidence of VAP.
antibiotic regimen reducing outcome severity. Methods
Subglottic suction prior to extubation should be
of rapid accurate sampling include bronchial alveolar
lavage (BAL or mini BAL) performed by the respiratory
Use Closed Suction System (CSS) — CSS provides a
therapist or other trained caregivers or specimen
barrier to separate the contaminated catheter from the
retrieved by brush, biopsy, swab or lavage
caregiver and other patients as well as reduce the
bronchoscopy conducted by a pulmonologist.
environmental exposure of the patient being suctioned.
Write policies, educate staff and monitor compliance —
Closed suctioning also permits continuous ventilation
Although positioned last in this list, institutionalization of
reducing respiratory stress and vulnerability. CSS is
recommended by the American Association for
accomplished by integrating them into facility policies,
Respiratory Care (AARC) as part of an infection control
routinely educating staff and monitoring for compliance
—absolutely necessary for reduction of VAP.
This brochure was originally developed for Infection Control Week 2004,
Minimize Saline Lavage — Research does not
Nosocomial pneumonia is the most deadly form of
support the routine use of saline lavage. Some
hospital-acquired infection. Patients receiving mechanical
studies have shown that the practice may be
intubated — A cuff that is under-inflated forms
ventilation are especially at risk. Intubated patients are
detrimental to the patient as bacteria may be
creases that can readily allow contaminated secretions
approximately 20 times more likely to develop pneumonia
dislodged from the catheter and endotracheal tube
to migrate past the cuff and aspirate into the lungs. The
than non-intubated patients. The endotracheal tube
into the lung while simultaneously causing oxygen
optimal pressure for all situations has not been
interferes with normal patient defenses by blocking
conclusively established but is generally held to be 20
mucocilliary ladder, interfering with gag and cough
recommend the use of saline sparingly for thick
mm/Hg. Cuff pressure should be monitored and
reflexes and allowing pathogens direct access to the
secretions. It is important to note that this does not
recorded routinely. Avoid excessive inflation as too
lung. Ventilator-associated pneumonia (VAP) continues to
exclude thorough and complete rinsing of CSS after
much pressure can prevent adequate perfusion of
occur in 8 to 28% of this vulnerable population. VAP
suctioning which is necessary to prevent colonization
accounts for 60% of all deaths due to hospital-acquired
condensate —Warm expired air condenses in
endotracheal tube — Manipulation of the tube
ventilator tubing. Microbial growth occurs rapidly in
creates creases and gaps in the cuff which can allow
the pooled condensate. Disconnection of the circuit
contaminated secretions to slip through and drop intothe lungs.
Increased hospital charges attributed to nosocomial
and manipulation to drain the tubing can cause the
pneumonia are approximately $40,000.
contaminated condensate to dump directly into the
Remove tube as early as possible, but avoid
lungs. Condensation traps permit drainage without
re-intubation — Early tube removal has been shown
opening the circuit, preventing both microbial dump
to reduce VAP. However, if the patient is not ready and
and contamination from the external environment.
must be re-intubated, the process will increase VAP risk.
The mortality rate ranges from 24 to 50% and can reach
Opening the circuit for other procedures should be
Noninvasive ventilation may be more appropriate rather
76% when high risk pathogens are involved. As the
avoided. Accumulation of condensate can also be
number of days intubated increases, so does the
reduced by the use of a heated wire in the expiratory
phase tubing or a heat-moisture exchanger (HME).
Prevent cross-contamination with reusable
However, care must be taken not to allow patient
devices — Use single use devices whenever possible.
secretions to dry, which can cause endotrachael and
Reusable items such as resuscitation bags,temperature probes, spirometers, humidification
VAP is a bacterial pneumonia. Infections which occur
apparatus and endoscopes must be subjected to
within 48 to 72 hours after intubation are referred to as
Perform subglottic suctioning when necessary
sterilization or high level disinfection to prevent cross-
“early-onset” and are usually antimicrobial sensitive. Those
The endotracheal tube prevents closure of the
contamination. Residual disinfectants should be rinsed
occurring after 72 hours, referred to as “late-onset”, are
epiglottis. Oropharyngeal secretions accumulate
off with sterile water, or when this is not possible, rinsed
often multi-drug resistant. The causative pathogens
above the endotracheal tube cuff, below the glottis.
with tap or 0.2 micron filtered water followed by alcohol
usually associated with these time periods are:
Microorganisms can grow in this protected
environment. Suction removal of these fluids can
reduce the risk of aspiration. Suctioning prior to
Selective decontamination of the digestive tract
is controversial — The use of an antibiotic paste for
repositioning or extubation should be standard
the mouth and stomach is gaining favor in Europe, but
Incline patient’s head whenever possible
has not been widely used in the US. This practice has
been associated with the emergence of antibiotic-
(Reverse Trendelenberg’s position) — The supineposition increases the accumulation of secretions in
the subglottic area. Elevating the head 30 to 45°
Vaccinate staff — Seasonal influenza vaccinations
reduces this pooling and thus the microbial load.
are recommended, as well as the 23-valent vaccine
against invasive pneumococcal disease (if indicated), to
Methicillin Resistant Staphylococcus aureus (MRSA)
possible — Nasotracheal intubation has been
protect staff and reduce nosocomial outbreaks.
associated with nosocomial sinusitis and high
incidence of VAP. The oropharyngeal route is
Copyright 2005, APIC. Limited copies permitted for educational, not-for-
profit use. Call 202/789-1890 x2629 for more info. Authored by D. Theron VanHooser M.Ed. RRT, FAARC and Wava Truscott, PhD, and reviewed by RosieFardo, RN, BSN, CIC, & Chris Nightingale, RN, BSN, CIC. 10/16/04
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